A Guide to Best Practices

1. A Guide to Best Practices February 2011

2. Training Objectives Learners completing this training module will: • Understand the concept, definition and types of best practices • Be able locate and identify best practice models, including those cited in SAMHSA’s National Registry, ADHS/DBHS focus areas, and CPSA initiatives • Learn the factors vital for the successful application and implementation of best practices We’ll begin with an overview of best practices…

3. Overview of Best Practices

4. Emergence of Best Practices Developments in the behavioral health field have placed greater emphasis on measurable outcomes. Funding sources often require outcome measures be in place as a requirement for funding. This has led to a focus on models of care and programs that lead to measurable improved client outcomes. As research evidence grows, certain models demonstrate overall effectiveness and have become best practices. In this module, you will learn about this topic and important related ideas.

5. What is a Best Practice? A best practice… …is a program, technique, method, process, or activity, regarded as proven (usually through research) to be effective at delivering a particular outcome or desired result when applied to a particular condition or circumstance. …consistently shows results superior than those achieved with other means. …can also be defined as the most efficient (least amount of effort) and/or effective (best results) way of achieving an outcome, based on repeatable procedures that have proven themselves over time for large numbers of people. …is typically research/evidence-based and consensus-driven.

6. Why Best Practice? • Best practices and behavioral health… In our field, there are many approaches or methods through which a member’s behavioral health issues might be addressed. However, given limited available resources, and our desire to effectively and efficiently help our members, it is wise for behavioral health staff to utilize best practices whenever possible. By employing best practices, time and resources will not be wasted on untried or unproven methods or services.

7. Best Practice Categories • There are several ‘categories’ of best practices, with category differences based upon the amount of scientific research conducted resulting in consistent positive outcomes. • For our consideration today, best practices are behavioral health interventions (programs or strategies) that can be described as one of the following: • Evidence-Based Practices • Promising Practices • Emerging Practices Let’s take a look at each of these categories …

8. Evidence-Based Practices Evidence-based practices (EBP) top the list of best practices with regard to their proven effectiveness and positive client outcomes, which are demonstrated through rigorous scientific research and evaluation. • Evidence-based practices… • are proven through research to be effective in addressing a given disorder, situation or problem. • are proven effective in various settings or contexts and with different populations (this is called replication). • are often published in peer-reviewed professional journals.

9. Promising Practices Promising practices are those for which there is preliminary evidence or expert consensus. They show promise in improving client outcomes, but are not yet proven by the highest or strongest scientific evidence. • Promising practices… • have limited supporting data that suggest their effectiveness in addressing a given disorder, situation or problem. • have potential for replication across settings, contexts and populations. • may be elevated to evidence-based practices after more research confirms or proves their effectiveness.

10. Emerging Practices Emerging practices are often innovative and address critical needs of a particular program, population, or system, but do not yet have scientific evidence or broad expert consensus support. • Emerging practices… • are usually not based on research or theory, but on anecdotal evidence and professional wisdom. • have minimal research evidence of replication success. • may be elevated to evidence-based practices after more research confirms their effectiveness. Next, a look at locating best practices…

11. FindingBest Practice Programs and Interventions

12. The area of best practices is somewhat fluid, as new practices are added and updated or upgraded (i.e. from promising to evidence-based). There are resources available for locating, selecting and implementing best practices. While not all best practices have been proven effective with all populations, pursuing best practices will allow you to make more informed choices when selecting effective services for your members. Finding Best Practices Where should you look to find current best practices? Continue for answers to this question…

13. In this age of the internet, you have many resources at hand for finding and learning about best practices. When searching the web, narrow your search to the type of best practice (i.e. - promising) and the specific disorder/diagnosis or situation (i.e. - conduct disorder or PTSD). Finding Best Practices One of the most useful sites for finding behavioral health best practices is the Substance Abuse and Mental Health Services Administration (SAMHSA) website…

14. Finding Best Practices SAMHSA: Leading the Nation… The Substance Abuse and Mental Health Services Administration (SAMHSA), an agency of the U.S. Department of Health and Human Services (HHS), was established in 1992 to focus attention, programs, and funding on improving the lives of individuals with or at risk for mental health and substance use disorders. SAMHSA works to ensure that all people receiving services in the behavioral health arena have the opportunity to live a fulfilling life that includes a job, a home, and meaningful relationships with family and friends.

15. Finding Best Practices SAMHSA’s Model Programs… To meet its goals, SAMHSA promotes the use of best practice models of care through the National Registry of Evidence-Based Programs and Practices (NREPP). This is a national resource of current and reliable information on best practices for preventing and treating mental health and substance use disorders. SAMHSA reviews models of care to determine if they meet best practice criteria. To visit the SAMHSA website click on their logo

16. Finding Best Practices SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP)click on to view …a good place to start reviewing best practices and interventions. The registry provides a brief program description and results data, as well as recognition information. • Intervention summary • Program background • Target areas and intended populations • Evaluation and design outcomes • Benefits For each best practice, details are also provide on: • Program fidelity • “How It Works” • Implementation history and information • References • Contact information There are many additional internet resources - some examples…

17. Finding Best Practices Resources for Mental Health Disorders Websites: A Guide to Evidence-based Practices on the Webhttp://www.samhsa.gov/ebpwebguide/index.asp American Counseling Association http://www.counseling.org/ American Journal of Psychiatry http://ajp.psychiatryonline.org American Psychiatric Association www.psych.org American Psychological Association www.apa.org Arizona Department of Health Services http://www.hs.state.az.us/bhs/bhlinks.htm National Institute of Mental Health http://www.nimh.nih.gov/

18. Finding Best Practices Resources for Substance Use Disorders Websites: Substance Abuse and Mental Health Services Administration http://www.samhsa.gov/ Society of Addiction Medicine www.asam.org Evidence-based Practices for Substance Use Disorders http://www.adai.washington.edu/ebp/ Motivational Enhancement www.motivationalinterview.org/library/TIP35/TIP35.htm

19. Finding Best Practices Resources for Child and Youth Disorders Websites: Austin Resilience Developmenthttp://www.friendsrt.com/resources.html Childhood Mental Health http://www.childhooddisorders.com/treatment.html Healthy Youth http://www.cdc.gov/HealthyYouth/mentalhealth/index.htm Reconnecting Youth http://www.reconnectingyouth.com/ Delinquency Prevention http://www.ojjdp.gov/mpg/

20. Finding Best Practices Additional Evidence-Based Practices Websites: Borderline Personality Disorder Dialectical Behavior Therapy (DBT) Seriously Mentally Ill WRAP Recovery Model (Mary Ellen Copeland) Depression Cognitive Behavioral Therapy (CBT) At-Risk Youth / Wraparound (Child & Family Team) & Family Systems Therapy Brief Strategic Family Therapy Multisystemic Therapy Substance Abuse Motivational EnhancementHarm Reduction

21. Best Practice Initiatives and Interventions

22. Initiatives Many best Practices become part of initiatives - areas of focus that are suggested or required for Behavioral Health entities to utilize. In this module section we will examine State focus areas and CPSA Initiatives that utilize and/or promote specific Best Practices.

23. State Best Practice Focus Areas In Arizona, current Best Practice models are identified by the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS)… • American Society of Addiction Medicine (ASAM) PPC-2R • Clinical and Recovery Practice Protocols • Dialectical Behavior Therapy (DBT) • Positive Behavior Supports (PBS) • Trauma-Informed Care (TIC) Let’s look at these state supported best practices…

24. State Best Practice Focus Areas American Society of Addiction Medicine (ASAM) PPC-2R ASAM PPC-2R seeks to match substance disorder clients to treatment by examining their multidimensional needs; identifying the variety and intensity of a multimodal treatment plan; and then assigning a patient to the most effective, efficient level of care. • a structure that uses biopsychosocial factors and criteria to plan implement and continuously assess the treatment of substance using clients • emphasizes multidimensional assessment; problem and priority identification within the context of severity of illness and the client’s level of function; treatment matching of needs to services and an intensity of service within a broad continuum of care; and finally ongoing assessment of progress and treatment response http://www.asam.org

25. State Best Practice Focus Areas ADHS/DBHS identifies some best practices through their Clinical and Recovery Practice Protocols. Those Protocols currently in use include: • The Child and Family Team (CFT) • Children’s Out of Home Services • Comprehensive Assessment and Treatment for Substance Use Disorders in Children and Adolescents • Psychiatric Best Practice Guidelines for Children: Birth to Five Years of Age To access the ADHS/DBHS Protocol webpage click on the flag Let’s take a look at these Protocols…

26. State Best Practice Focus Areas Protocol: The Child & Family Team (CFT) PURPOSE: To establish protocols that effectively operationalize the Child and Family Team practice and process. • describes how CFT practice activities are implemented with children and adolescents • defines the activities of the CFT in accordance with the 12 Arizona Principles • describes how the Child and Adolescent Service Intensity Instrument (CASII) is utilized http://azdhs.gov/bhs/guidance/cfttad.pdf

27. State Best Practice Focus Areas Protocol: Children’s Out of Home Services PURPOSE: To operationalize the use of best practice guidelines in residential treatment centers, BH group homes, and Home Care Training to Home Care Client (HCTC) provider settings to ensure youth receive treatment consistent with the Arizona Vision and 12 Practice Principles. • applies to all BH recipients under 21 years of age living in Level I, II or lll residential or HCTC (therapeutic foster care) settings • promotes the involvement of family in the youth’s services - where appropriate http://azdhs.gov/bhs/guidance/cfttad.pdf

28. State Best Practice Focus Areas Protocol: Comprehensive Assessment and Treatment for Substance Use Disorders in Children and Adolescents PURPOSE: To strengthen provider utilization of evidence-based, culturally relevant, and developmentally appropriate practices in the assessment and treatment of substance use disorders in children and adolescents. • provides guidance in the assessment, service planning, treatment and case management of youth with substance use disorders http://azdhs.gov/bhs/guidance/cfttad.pdf

29. State Best Practice Focus Areas Protocol: Psychiatric Best Practice Guidelines for Children: Birth to Five Years of Age PURPOSE: To define best practice guidelines for psychiatric evaluation and the use of psychotherapeutic and psychopharmacological interventions with children birth to five years of age. • services are conducted with caregiver collaboration • helps promote appropriate interventions for preschoolers with mental health issues http://azdhs.gov/bhs/guidance/cfttad.pdf

30. State Best Practice Focus Areas Dialectical Behavioral Therapy (DBT) A psychosocial treatment for those with Borderline Personality Disorder, (BPD) aimed at reducing parasuicidal (self-injuring) and life-threatening behaviors, behaviors that interfered the therapy/treatment process, and finally reducing behaviors that limit the client's quality of life. • its main goal is to teach the client skills to cope with stress, regulate emotions and improve relationships with others. • the first therapy that has been experimentally demonstrated to be effective for treating BPD • a cognitive behavioral therapy, meaning it is a therapy that focuses on the role of cognition (e.g., thoughts and beliefs) and behaviors (e.g., actions) in the development and the treatment of BPD http://www.dbtselfhelp.com

31. State Best Practice Focus Areas Positive Behavior Supports (PBS) PBS is an approach to helping children and families address challenging children’s behavior while learning new skills. It is a collaborative, assessment-based process that develops effective, individualized interventions. • utilizes behavioral analysis of the child and family • focuses on reinforcement of positive, desirable behaviors • behaviors are viewed in their environmental and social contexts • undesirable behaviors are assessed with regard to their function http://www.pbis.org/community/early_childhood/family-centered_pbis.aspx

32. State Best Practice Initiatives Trauma-Informed Care (TIC) Trauma-informed care is an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. • incorporates knowledge about trauma - prevalence, impact and recovery - in all aspects of service delivery • care and services are grounded in and directed by a thorough understanding of the neurological, biological, psychological and social effects of trauma and violence on humans • utilizes the perspective that trauma is a pivotal force that shapes clients’ mental, emotional, spiritual and physical well-being • emphasizes an understanding of how the past impacts the present Next up - CPSA’s Best Practices Initiatives… http://www.samhsa.gov/nctic

33. CPSA Best Practice Initiatives The Best Practice Committee oversees the ongoing implementation of best practices with members in the behavioral health system. The goal is to increase staff’s competency in these approaches selected and provide effective coaching to maintain fidelity to the models. The Committee is made up of CPSA staff and key personnel from many of the Comprehensive Service Providers and Service Providers in the CPSA system. Let’s look at the programs that are the current focus of CPSA’s Best Practice Initiatives…

34. CPSA Best Practice Initiatives CPSA’s Best Practice Initiatives focus on those interventions and tools that enhance the effectiveness of services and help to measure/promote positive outcomes for our members: • Behavioral Interventions (BI) • Motivational Interviewing (MI) • Outcomes Rating Scale/Session Rating Scale (ORS/SRS) Trainings on these interventions and strategies are offered by CPSA! We’ll take a look at each of these programs…

35. CPSA Best Practice Initiatives Behavioral Interventions (BI) BI explores basic strategies and behavioral techniques with individual members - usually children - with cognitive impairments and developmental disabilities. • utilizes the fundamental theory and evidence-based practice of behavioral interventions, Functional Behavior Assessments (FBA) and Positive Behavioral Support (PBS) • identifies antecedent, behavior and consequences surrounding undesirable behaviors and determines specific, measurable and re-enforceable replacement behaviors • incorporates environmental modifications to help minimize undesirable behaviors www.counselingconsulting.org/development-disabilities.html

36. CPSA Best Practice Initiatives Motivational Interviewing (MI) MI is a client-centered, directive method for enhancing an individual’s intrinsic motivation to change by exploring and resolving ambivalence. It is a process of interviewing, assessing, and actively motivating clients. • appropriate for most populations and for most age groups • compared with nondirective counseling, it is more focused and goal-directed • recognizes the fact that clients approach counseling at different levels of readiness to change their behavior • clients are responsible for their progress - MI focuses on clients' sense of self-efficacy www.motivationalinterviewing.org

37. CPSA Best Practice Initiatives Outcomes Rating Scale/Session Rating Scale (ORS/SRS) These two scales are brief instruments/tools for monitoring the process and outcome of treatment services • ORS and SRS measures are designed for use at the beginning (ORS) and end (SRS) of every session. • both come in versions for use with children and adults • ORS is designed to assess areas of life functioning known to change as a result of a therapeutic intervention • SRS is designed to assess key dimensions of effective therapeutic relationships http://www.csustan.edu/social_work/F08%20SW5032PMEnglish.DOC

38. Applications of Best Practices

39. Application of Best Practices Best practices are not intended to be automatically and uniformly applied in every situation. Instead, providers should integrate research evidence, clinical expertise, and the values, needs, concerns and cultural preferences of the clients they serve when selecting appropriate best practices. • When selecting and providing an evidence-based intervention, there must be a balance among these essential components: • the best science-based evidence • the skill, judgment and experience of the behavioral health care provider • the unique needs, concerns, and preferences of the individual or family receiving the service • the need to stay true to the model (fidelity) Let’s look at each of these components …

40. Application of Best Practices Scientifically-Based Interventions When appropriate, best practices, and research-proven interventions and strategies should be utilized. When research shows that a specific intervention may benefit an individual or family, we must consider this intervention as we formulate a service plan. While every client may not benefit, the research indicates that strong consideration of the intervention is necessary in these decision making situations. There is more to consider than proof of a program’s effectiveness…

41. Application of Best Practices Skill & Judgment of Health Care Providers Ethical practice requires that behavioral health providers be qualified and competent when providing a specific model of care - clinical expertise. These necessities are outlined in all professional Code of Ethics, including in behavioral health fields. Ethical practice includes providing services within the boundaries of a provider’s education and training, with adequate supervision - especially when learning and utilizing new techniques or approaches.

42. Application of Best Practices The Unique Needs and Preferences of the Client Receiving Services In addition to a proven model and the competency of the practitioner, considering the uniqueness of each individual/family receiving services is vital. The provider’s ability to identify and accept the values of the individual receiving services and to form a relationship based on mutual respect will increase the likelihood of positive outcomes. When considering strategies or programs, look for a ‘fit’ with the member and/or the family.

43. Application of Best Practices Staying True to the Model (This is called fidelity) It is critical to evidence-based practice to follow the model design, program guides and manuals. Why? The extent to which program implementation and practices replicate the original model directly affects effectiveness and outcomes. In addition, the best practice has become a best practice due to its effectiveness according to the model. If you find yourself having to significantly ‘adapt’ a program or strategy to fit your member/family, consideration of a different program may warranted.

44. Putting It All Together

45. Putting It All Together The Clinical Relationship It must be remembered that, while the selected tools, strategies and interventions are critical in moving therapeutic progress forward, the clinical relationship between professionals and members is still key. While using best practices can be very helpful to improve outcomes, the importance of engagement and the therapeutic relationship between the provider and the individual cannot be ignored. To foster this engagement and build the relationship, respect, trust, listening, caring, and the bond that develops between people must be encouraged.

46. Putting It All Together Involving the Individual The member’s self-determination is necessary to provide services that lead to the best outcomes. The individual receiving care has the right to agree or disagree with a potential best practice. Person-centered services are empowering, placing trust and responsibility on the individual. This illustrates that the individual member or family are active players in their own recovery. When selecting and implementing best practices, considering the individual’s and family’s strengths and culture, as well as their readiness to change, helps to secure member involvement and enhance the clinical relationship.

47. Putting It All Together A Full Partnership Successful outcomes depend on the partnership of all the clinical team members. Discussing best practices with the team and the individual and his/her family is necessary. Using terms such as evidence-based practice or best practice may not be appropriate, but explaining the reason a specific model is chosen, and its intended outcomes will be helpful. Let’s consider a couple of scenarios…

48. Putting It All Together A Scenario… You have started working with an individual, Samaria, who has a disorder about which you have limited knowledge. You would like to know about best practices for addressing her disorder. What steps might you take to determine best practices that might assist in serving Samaria? Go to SAMSHA, ADHS/DBHS or other websites to research best practices? Search the CPSA website? Talk to others with more experience with this disorder? See next slide for answer…

49. Putting It All Together Did you chose to pursue all three options? Each of the choices have merit and are correct depending on the situation and the resources available. Doing all three might be the best path for you to take. In your agency, there are likely to be experienced behavioral health professionals with well-developed skills and large knowledge bases. These individuals are excellent resources who may offer beneficial ideas, suggestions, and recommendations to assist you in your pursuit and application of a new best practice.

50. Putting It All Together Another Scenario… Think about a best practices in regard to the following: You are working with an individual, Will, whose family has been continuously uninvolved in his recovery. You have learned about a best practice that addressed Will’s disorder, but it calls for the commitment and involvement of family members. What do you do? What must be considered? See next slide for answer…